as well as by clinical experience, shows that if we intervene at all with
hope of betterment, the earlier it is done the better. The general rule
has been that of Lauenstein,' that if after from six to ten weeks there is
incontinenei! of urine and fieces, with cystitis and bed-sores, little is to
be hoped fnjm Nature's efforts and an operation is justitiable.
Horsley,"'' however, is nmcli more emphatic in his opinion, and .says:
"In all cases where disj)lacement or crepitus indicates eomjtression, and
where extension directly after the accident fails to reduce the displace-
ment, we should operate in case there are symptoms which show an
interference with the functions of the cord." In view of the rare but
undoubted instances of good results following early o|)cration, the tend-
ency of modern surgeons is to nnich earlier rather than later interfe-
rence. The case already cited (p. S2"2) from tSchede is an excellent illus-
tration. BurrelP has analyzed 1(J8 cases of fracture of the spine, and
has not only given uj) his earlier plan of crushing back the fragments
into place, which in the last 8(J eases had given .").'> per cent, of recovery
as against 22 per cent, following the expectant plan in the first 82 cases,
but advocates ojieration in all cases of fracture within the first twenty-
four hours, includinsi' even those in the cervical reaion.
Golding Bird * has re])orted another case of oi)eration on the second
day after fractui'e of the eleventh and twelfth dorsal laminse, causing
almost comjjlete para|)legia from compression of the cord by the dis-
placed lamiiue. In eighteen days the j)atient seemed quite well. Ride-
nour'' o]>erated one hour after fracture of the seventh and eighth dorsal
with a displacement of the seventh dorsal of over one inch, the mem-
branes l)eing torn and the cord compressetl. The operation was followed
by a rapid return of the sensibility and of control over the bladder and
bowels. In three months the patient could walk with the aid of a
jacket. Villar'' operated three days after a fracture of the twelfth
dorsal with complete jKirapIegia, loss of ])lantar and testicular reflex, but
l)ersistenee of the knee-jerks, which were subsequently lo.st. His patient
regained control of the bladder and bowels and could move his legs, but
was not able to walk. All pain had disappeared. Knox ' operated
thirty-six hours after fracture and luxation of the eleventh dorsal ver-
tebra. On the following day sensibility had completely returned, with
slight motion. Ten months later he could sit up and take some steps
without support.
' Cenirulhl. f. CIdr., 1886, p. 888. ^ Bi-lt. Mfd. Joiirri., Dec. 6, 1890.
■'' Ibid., Oct. 2, 1894. « Ibid., 1891 , i. 1 124. o Chipault, p. 96.
' Columbus Med. Jouni., 1891-92, x. 151. ' Glasgow Med. .lonrn., 1893, 249.
FEACTUliE.S OF THE SPINE.
825
Fig. 474.
Of course but few eas^es will .><lio\v such marks of improvement, but
had tile ojienition been delayed in the.se ca.ses it is almo.st certain that
they would all have died from myelitis after months of sutfering.
Dawbarn ' reports the ease of a young woman who had fallen four
stories and fraetured her spine. Complete motor paraplegia and almost
complete .-iensory paralysis followed. Two and a hall" hours after the
injin-y he did laminectomy. The eleventh and twell'th dorsal vei'tebrae
were found crushed in several places, with two jioiuts of bone projecting
into the dura and apparently into the cord. The arches were removed
with the rongeur forceps. The dura was slit for four inches. Blood-
clots were evacuated, and the cord was found distinctly indented, but
apparently not actually lacerated, nor was there any loss of substance.
On jiassing a probe beneath — that is, anteriorly to — the cord, resistance
W'as met op])osite the twelfth vertebra, due to the projection of a sharp
.spicula of bone, like the end of a
lead-pencil, compressing and appa-
rently sticking into the anterior sur-
face of the cord. It was reached with
great dithculty and removed, the arch
of the vertebra being gnawed away
with the rongeur forcej)s nearly to
the body of the bone. Sharp hem-
orrhage from wounding of a vein
followed the removal. ^^'hen this
was controlled by two long stri]is of
iodoform gauze inserted under (in
front of) the cord and halfway en-
circling it, the dura was sutured and
the wound clo.sed except for the gauze
drain. .V plaster-of-Paris splint was
applied from the arm])it to below the
hips. The gauze was removed be-
tween the second and third days
through a trajt-door in the splint.
Paralysis of the bladder and rectum
continued for a month ; after that,
under .strychnine, massage, and electricity, she improved, .«o that ten
months after the accident she resumed her work as hou.semaid and cook.
The right leg was slightly weaker than the left, but not sufficiently so to
aflect the gait, nor has the sensibility been fully regained.
The result in this ease seems to be attributable, as tlie author believes
(an ojiiniou in which I fully concur), to the immediate operation. Had
such fragments of bone been allowed to press upon the dura and cord
for any length of time, uiKpicstionably myelitis and meningitis would
have followed, and the patient's health, if not he.- life, would have been
sacriticed.
Chipault- has recently reported a similar noteworthy case of fracture
of the eleventh dorsal, ^vith disjilacement backward of a bony semicir-
cular i'ragment compressing the cord, in which recovery followed f)pera-
' Annals of Surg., Jan., 1895, p. 46.
^ La NouveUe Iconoyraphie de ta SalpSlriire, 1894.
Backward liisnlaccment of the fractured
lamina of tne eleventh dorsal vertebra,
compressing the cord (Chipault).
82(j Till'. SUIKIKRY OF THE Sl'LXK
tion (Fig. 474). Tlu' young niaii tVll from a roof. There was great
pain at the eleventli dorsal spine, without any (h-t'orniity. Tiie left leg
was paralyzed, including the muscles of the left huttock, hut the loft
sartorius was only paretic. There were amesthesia and analgesia (without
thermic ausBsthesia) of the penis, scrotum (partial), tiie perineum, the
l)uttock (partial), posterior surface of the right thigh in a thin l)and, and
all the ])arts below the knee, with slight anajstlicsia ol' the left foot.
The cremaster reflexes were preserved, the knee-jerks slight, the [)lantar
absent. On the eleventh day laminectomy was done. Improvement
began at once, and a year and a half later he resumed an active and
laborious occupation, carrying on his back very heavy weights, and his
lumbar suppleness was normal. The reflexes were normal.
Besides this, it must be rememl)ered that while the early results of
operation may be a donl)tfnl improvement, yet gradually, after, it may
be, a year, the improvement may be very marked. Hence we should not
despair of any ease until at least a year after operation, and meantime
not only should all the usual hygienic methods be employed, such as
good diet, change of air, bathing, and attention to the bladder and bowels,
but also massage of the jwralyzed extremities, witli galvanism or faradisni
as may be re({uired, should be persistently employed.
Second/i/, the HHc of the Lesion as Tnflnciiciin/ the Decision to Operate. —
In general it may lie said that the higher the lesion the less favorable the
prognosis, and therefore the less should we be disposed to interfere. Al-
though there are a few cases reported not only of operative recovery, but
also of good recovery of function, following ojH'rations in the upper dorsal
region, yet we may say in general that operation above the seventh
dorsal will rarely be of value, and should only l)e undertaken when the
symptoms and collateral conditions are entirely favorable. In the lower
dorsal and the lumbar regions the prognosis is considerably more favor-
able, provided that evidences of scvei'e lesions of the cord are absent,
and l>elow the second lumbar it is almost a rule that ojieration should be
undertaken. The cord, as is well known, terminates at the lower border
of the first hunbar vertebra. From that point to the end of the sacrum
we have a leash of nerves known as the cauda ecjnina, and an injury to
these nerves is really an injury to peripheral nerves, and not at all an
injury of the cord. In such cases, even at a late period, operations can
be undertaken with advantage.
Here again, however, the rule should be for early interference rather
than late, so that the s( lurce of compression or laceration may be removed
and any later additional compression from callus may be avoided. If
the nerves of the cauda etpiina are divided, they should be sutured pre-
cisely as any other peripheral nerve, and the far greater success of pri-
mary suture over secondary is an additional argument in favor of early
operation, which should be immediate if the evidence of laceration or
compression is positive, or within a few days afterward, or at least so
soon as the shock of the injury has passed, \vhen time has been given to
show that it is not merely a contusion of the nerves. The same rule
would apply also to all lesions of the nerve-roots at other points in the
cord. They are peripheral nerves the moment they leave the spinal
cord.
Of course, if the fracture is limited to the arches with displacement
FRACTURES OF THE SPiyE.
827
i])C'rate in any region
such as to cause pressure on the cord, wc sIkh
of the spine.
Thir/l/i/, the Amount of Interference which is Alloinible. — In very
many oases surgeons have contented themselves witli the more or less
complete removal of the jRtsterior arches. If the fracture is limited to
these, this is quite sufficient, but if the fracture or fracture-dislocation
involve the bodies of the vertebra?, there is not uneommonlv such a dis-
j)lacement of a portion of the body of the vertebra as to produce two
causes of compression — one posteriorly in the arches, the other, and
more frequent and serious, anteriorlv in the bodies of the vertebrte
(Fig. 475).
It is not good surgery to remove only one source of compression and
leave the other, and, inasmuch as the cord can be drawn to one side to a
Fig. 475.
Fig. 476.
old dorso-lumbar fracture, with permanent
disiilacement (Chipaultl.
Lateral displacement of the cord to expose the
posterior surface of the bodies of the vertebrae
(Chipaultl.
very considerable extent (Fig. 476), it is much better to do this and to
remove the ])rojecting portion of the hotly of the vertebra?. This can
be accomplished by the careful use of a chisel, gouge, or curette. The
degree to which the cord can be displaced laterally is very considerable,
and if traction be made on one side and then upon the other with an
aneurysm needle or with a narrow blunt retractoi, the posterior surface
of the bodies t)f the vertebra? can be reached. Just how far such opera-
tive procedures on the bodies of the vertebra" may be justifiable and
successful we are at present not in a jiosition to e.vpress a positive
opinion.
The techni(|Ue of the operation is described on p. 858.
Besulta of Operation. — After all, the question as to whether an opera-
828 THE SURGERY OE THE Sl'ISE.
tion should bu donu or not dopciids upon tlie results oljtaiufd. (Jurlt
has recorded 217 deaths out of a total of 1^70 fVat'turcs treated without
operation (a mortality of ISO per cent.), and it nuist be eonfessed that in
many oi' the 20 per ('ent. who recoNeri'd life was scarcely worth the
living. On the other hand, Thorburn has collected 61 cases of opera-
tion of which 35 died, or only 57 per cent. In some of those who
recovered the recovery was almost complete, \\\\\\q in those who still
suffered from [laraplegia the improvement in the bed-sores, the retfain of
control over the vesical and anal sjihincters, made life much more bear-
able, thouo-h still depressing. C'hipault has tabulated 104 cases of opera-
tions of all degrees of severity — chietly gunshot fractures, however —
from 1750 to 1891. Of these, the result was unknown in 9, leaving 95
terminated cases: 8.3 of these cases were operated on prior to 1878, in
the days bef(jre antiseptic surgery. AVith modern methods the results
Mould undoubtedly have been better. Yet of the 95 cases only 38 died,
a percentage of deaths of 40 per cent, and recoveries 60 per cent. Again,
Lloyd ' has collected 103 traumatic cases operated on, with 58 deaths
(mortality 57.3 per cent.) ; of those treated antiscptically, 50 per cent,
died; of the non-antiseptic cases, 63 per cent, died ; of the latter only 1
was cured (2 per cent.), and 7 recovered partially (16 per cent.) ; of the
former, 4 were cured (6 ])er cent.), and 15 recovered j)artially (25 per
cent.). With such statistics before us it is impossible to draw any other
conclusion than that i>peration is advisable "in case extension directly
after the accident fails to reduce the deformity " (Horsley). Of course
the limitations arising from the time that lias elapsed since the accident,
the region involved, and the severity of the lesion must be given due
weight in reaehino- a coiielusion in anv jriven case.
In an accident, therefore, of such gravit_y, followed by such an im-
mense percentage of deaths if no operation be done, it would seem to be
advisable with our present exjjericnce, in all suitable cases, to give
patients the real though often desperate chance that operation affords,
and that the operation should be done at a much earlier period and
more thoroughly than has hitherto been the rule.
The far greater success which has followed operation in the region of
the Cauda equina justifies the conclusion of C'hipault,'- that —
" (a) In case of lumbar or sacral fracture, with permanent and irre-
ducible displacement of the bony fragments, we should interfere at
once.
" [b] In case of fracture which is reduced either spontaneously or by
surgical manipulations, wait. If the course of the case is toward re-
covery, wait ; if the case remains stationery, intervention is justified
toward the end of the first month — not earlier, since functional restora-
tion may not begin till toward this period ; not much later, since incura-
ble spinal degenerations may l)e established."
Treatment. — The (juestion of operation in various regions has already
been considered while treating of the symjitoms and the diagnosis. The
technique of the operation will be found on p. 858. Only the non-
operative portion of the treatment, therefore, remains to be considered.
The trans])ortation and immediate care of the ]iatient are important.
Every precaution should be observed to prevent further laceration of the
' Amer. Journ. Med.Sd., July, 1891, 25. ^ Eludes de C'hir. mediU., p. 71.
GUNSHOT FRACTURES OF THE SPIXE. 829
cord, as well a.s to prevent severe i)aiii, by liaiulling him with the utmost
gentleness. In placing him upon a stretcher or the bed, esj)ccially if the
fracture-dislocation be in the cervical region, the head and neck sliould
not be Hexed or rotated, and they should be immoljilized by cushions or
pillows or s;ind-pillovvs jilaced on each side of the Iiead. Cautious trac-
tion under an ana'sthetic in most cases may be made to reduce the
deformity if it exists. Even in cases with imperceptible pulse and ster-
torous breathing such reduction may be followed by ])artial or even
most complete recovery. To be successful no time should be lost, but
the reduction sliould be made witliin the first few hours or davs after the
accident. If in the dorsal or lumbar region, after tlie deformity has been
reduced a plaster-of-Paris jacket may be used with advantage to retain
the fragments in place, together with extension to the head or legs, or
both, by means of weights and pulleys. In apjilying the jacket the
patient should be suspended (as in applying the ])laster jacket in Pott's
disease), but the surgeon sliould be on the watch for aiiv unfavorable
symptoms, and an aniesthetic sliould never be emjiloyed. instead of
being suspended, he may be jilaced between Uvo tables, which are then
gradually separated to a sufficient extent. In the space between the
separated tables the jacket can be applied while the patient all the time
remains in the horizontal position. The use of the plaster jacket has
been ftillowed by paraplegia or excessive pain, which disappeared after
its removal. The effects of the use of the jacket must, therefore, be
carefully watched.
The subsequent treatment will consist in the suitable administration
of opiates for pain, careful regulation of the diet, attention to the bladder
and bowels, scrupulous avoidance (if possible) of bed-sores, and later in
the use of electricity, massage, douches, passive exercise, and, still later,
the active use of the limbs as the patient regains control over them, if
indeed he ever do so.
Gunshot Practuees of the Spine.
Gunshot wounds are received, of course, in the majority of cases,
during war, though one sees them occasionally in what may be called by
courtesy, in such instances, civil practice. They are not uncommonly
immediately fatal. In the cervical i-egion tliis may follow from a wound
.so high as to produce paralysis of respiration. The vertebral artery also
may be wounded, and the patient die from either primary or secondary
hemorrhage. If the ball penetrate the chest or abdomen or pelvis, fatal
lesions may occur by jjerforation either of the heai-t or the aorta, or by
penetrating wound of the viscera, such as the bladder or intestines, fol-
lowed by extravasation and peritonitis. Even should death not occur
from such complications, it ver}' frecpiently follov.s, as in ordinary frac-
tures of tlie spine, from exhaustion, bed-sores, pysemia, or septic pneu-
monia, or, on the other hand, from m^-elitis and osteomyelitis, the direct
result of injury to the cord or the vertebra;. Not nncommonly necrosis
of the vertebne occurs. The most remarkable instance of this that I
have ever seen, especially as the patient recovered so well, is reported by
Mitchell, Morehouse, and Keen.' A young man, aged t\venty, was
' GuHiihol Wuiiinls anil ollwr Jiijiififx nf Xerrex, p. 28.
830 THE SURGERY OF THE SPL\E.
wounded in tlic hiittic of ( Jetty sburg, July 2, 186;], by a minie-ball,
\vhi(rli wounded the up])er li]> and the teeth and penetrated the body of
tlic third ceryieal vertebra, where it lodged. A niontli later the ball was
located by Nelaton's probe and was removed. Tlie man was paralyzed
for a time in all four extremities, but rapidly reco\'ered from the par-
alysis, and was placed on duty as a hospital attendant. Nearly a year
later a large part of the body of the third cervieal vertebra was spon-
taneously diseharged through the pharynx. The speeimen showecl the
anterior half of tiie transverse process of the vertebra, including the an-
terior border of the vertebral foramen.' No injury, however, to the
vertebral ai-tery was discovered. Eight years later the man was alive,
and a pension examiner reported that the right side of his tongue was
distorted, leaving his speech aifected, the right side of the throat con-
tracted, his right shoulder and arm atrophied and partially useless.
The fatality of such accidents is, of course, very great. During our
late Civil War there were 642 cases of gunshot wounds of the spine
reported, of which 349, or 55 per cent., proved fatal : many of them, of
course, did not involve the cord. The mortality in the cervical region was
70 per cent., in the dorsal 63.5 per cent., and in the lumbar 45.5 per cent.
The diagnosis of such injuries is, of course, easy as to the fact, but as
to the amount of injury is often very difficult. A disinfected finger can
sometimes be introduced, and \vill give us important information. If
not, a very carefully-introduced disinfected probe may be also valuable,
Fio. •177.
Showing the hole made by the missile (a conoidal pistol-ball) tlirouf,'li the body of the first lumbar
vertebra, iu the case of President Garfield. A probe penetrates each orifice (Army Medical
Museum specimen).
but, as a rule, neither of these means, especially the probe, is necessary,
and usually is inadvisable, inasmuch as the symptoms will generally give
us information of what injury has been inflicted upon deeper structures
which can be reached neither by the finger nor by the probe. The well-
known case of President Garfield (Fig. 477) is an illustration of how
' By an error in print this was described as the "carotid" instead of the "vertebral"
foramen.
GUNSHOT FMACrVRES OF THE SPINE.
831
Fig. 479.
tlifficult it may sometimes be to come to a proper conclusion. (Figs. 478
to 481, from tiie Army Medical Museum, illustrate various forms of
gunshot \voun(ls of the spine.)
Treatment. — In many cases of
gunshot wounds of the spine other
lesions of a pmhahly fatal charac-
ter will most likely forbid any in-
terference ; but if this is not the
case, the surgeon should not hesi-
FiG. 478.
Gunshot fracture of the hoily luul loft trans-
verse process of the ninth <lor.sal vertebra.
The missik' and nine fragments of the bone
are also slmwn (specimen 5738, Army Med-
ical Museum).
tate to operate in favorable cases,
very clearly indicate its advisability.
Fio. 480.
Gunshot fracture of the third lumbar
vertebra, with the missile attached
(specimen 2531, Section I., Army Med-
ical Museum).
The statistics of Chipaiiit (p. 169)
Of course the surgeon must care-
fully observe antise}>tic j)recau-
tions, and no interference with
the wound, cither bv the finger
or the probe or any other instru-
ment whatever, should be al-
lowed, unless both the wound,
Fig. 481.
The fifth, sixth, seventh, an. 1 .-iu'lith liur.^al v.-rtebr^c
with the body, etc. ofthfii ft h 'lividni hnrizontally.
and a conoiflal muskot-bjiU (also liiviik'd) liidj,'t'd
in the spinal canal {specimen 3894, Seetiun I,, Army
Medical Museum).
Gunshot fracture of the spinous process
of the second lumbar vertebra, with the
missile impacted between the lamina*
of the first and second (specimen 611,
Section I., Armv Medical Museum).
the hand, and the instrument have been most earefully disinfected.
If the wound involves the vertel)rH? alone, and not the cord, it would
832 THE SURGERY OF TITE SPLVE.
always be proper after disiiifectioii to make a suitaMc incision, to remove
all loose spienhe of l)onc, and to introduce a small drain of iodoform
gauze.
Gunshot wounds involving the cord are divided by N'ineent' into
three classes : First, those in whieh the cord is compressed by extrava-
sation of blood, fragments of bone, or by the projectile itself lying out-
side of the me(kdla or canal. It is evident in sn(;h cases that ojieration
would be jiroper, since we may be able to remove the source of the com-
pression, and if so at least do no liarm and with a possible ])r()spect of
improvement.
Second, those in which the projectile in passing tln-ough the spine
has injured the cord. As an exact diagnosis of the amount of injury
cannot be made without an ojieration, and as an operation will not likely
inflict serious additional injury u])on the j)atient, and may place the
wound in a more favorable condition for cure, it would be proper in
favorable cases — which are uuibrtunately I'are — to exj)lore, unless other
fatal and especially visceral lesions are present. If, however, the evi-
dence points to an extensive and ])crhaps total transverse lesion of the
cord, it would be better, in my opinion, to refrain from any operation.
Third : the cases in which the projectile has lodged in the sj)inal canal.
An operation then should be done, as it is almost absolutely certain that
the wound will be followed by meningitis and myelitis, and death be
brought about by exhaustion, bed-sores, and cystitis. The large mortality
already alluded to in injuries of the spine — a percentage which would be
very much greater were it limited to those in wliich tlu^ sjtinal cord is
involved^s at once an incentive to operation, whicli may possibly relieve,
but at the same time a warning that the great majority of cases will die.
The surgeon, therefore, should not be led to make any other than the
gravest prognosis, and should only operate in cases in which the con-
ditions are favorable.
Dislocations of the Spine.
While very frecpiently the violence which is sufficient to produce dis-
location also ])roduces fracture, yet autopsies have sho^\•n tliat there is a
large proportion of ])ure dislocations. Thus, Ashhurst reports of 394
cases, 124 with pure dislocations. The diagnosis of dislocation from